COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

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STATE OFCALIF0, RNIft WATER RESOURCES CONTR ' OARD FORM 'B': UNDE GROUND STORAGE TANK PRO RAM A= TANK PERMIT APPLICATION INFORMATION ' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 51 G FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 3 B. MANUFACTURED BY: � C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MAR D,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM O. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL F-11 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS E] 80 EMPTY ❑ 95 NKNOWN ❑2 WASTE E]7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONL IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED TH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTA MENT ❑99 OTHER ❑ 1 STEEL/IRON 2 STAINLESS STEEL3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK FF' CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING E] EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINY WRAP ❑4 FIBERGLASS REINFORCED PLASTIC,K. PROTECTION [:]5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKN WN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERG UND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 4RAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LI D TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POL INYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL LAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHE V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,KPRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELE TRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UN OWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALL S INERT MATERIAL? F-]YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF Y KNOWLEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY E JURISDICTION# AGENCY# FACILITY ID# TANK ID#3 / O 0Q L:�] GENCY FACILITY I APPROY BY NAME qy� PHONE S WITH AREA CODE PERMIT APPROVAL AT RMIT PIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPT# riy--- FORMB(6-29-88) I THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY